Immediate Assessment: A) Airway B) Breathing C) Circulation, cerebral
perfusion, and primary complaint
D: Drugs and diagnostic tests
E - Equipment
Patient Safety Considerations - ANSWER: Risk of Pressure Injury
Delirium
Infection
Falls
Airway - ANSWER Patency - Having the patient talk, or witnessing the
patient's chest rise and fall.
Position of artificial airway (if applicable)
ANSWER: Endotracheal tube.
Note the size and position of the airway.
Take note of the marking closest to the teeth, lips, or nares for future
comparisons to ensure accurate placement.
Suction the upper airway, either through the oral cavity or an artificial airway
, , to ensure that it is free of secretions.
Observe and record the quantity, colour, and consistency of any secretions
removed.
Breathing - Answer Quality and quantity of respirations (rate, depth, pattern,
symmetry, effort, usage of accessory muscles)
Breath sounds
Existence of spontaneous breathing.
Observe the rate, depth, pattern, and symmetry of breathing
The effort to breathe
Use of auxiliary muscles.
Breathing in time with the ventilator
Circulation and cerebral perfusion - ANSWER ECG
Rate, rhythm, and ectopy
Blood Pressure
peripheral pulses and capillary refill.
Skin colour, temperature, and wetness.
Evidence of bleeding
Level of consciousness and responsiveness
Quickly palpating a pulse and checking the ECG
perfusion, and primary complaint
D: Drugs and diagnostic tests
E - Equipment
Patient Safety Considerations - ANSWER: Risk of Pressure Injury
Delirium
Infection
Falls
Airway - ANSWER Patency - Having the patient talk, or witnessing the
patient's chest rise and fall.
Position of artificial airway (if applicable)
ANSWER: Endotracheal tube.
Note the size and position of the airway.
Take note of the marking closest to the teeth, lips, or nares for future
comparisons to ensure accurate placement.
Suction the upper airway, either through the oral cavity or an artificial airway
, , to ensure that it is free of secretions.
Observe and record the quantity, colour, and consistency of any secretions
removed.
Breathing - Answer Quality and quantity of respirations (rate, depth, pattern,
symmetry, effort, usage of accessory muscles)
Breath sounds
Existence of spontaneous breathing.
Observe the rate, depth, pattern, and symmetry of breathing
The effort to breathe
Use of auxiliary muscles.
Breathing in time with the ventilator
Circulation and cerebral perfusion - ANSWER ECG
Rate, rhythm, and ectopy
Blood Pressure
peripheral pulses and capillary refill.
Skin colour, temperature, and wetness.
Evidence of bleeding
Level of consciousness and responsiveness
Quickly palpating a pulse and checking the ECG
